Renoprotection: a matter of blood pressure reduction or agent-characteristics?

Data from recent clinical trials show that lowering of BP reduces the rate of renal function loss in chronic renal disease. There is evidence supporting the assertion that BP lowering obtained by intervention in the renin-angiotensin-aldosterone system (RAAS) has an additive renoprotective effect in both diabetic and nondiabetic renal diseases. However, to dissociate BP-dependent and non-BP-dependent action of RAAS blockade, the relevant trials are in many cases flawed by design, resulting in BP differences between the comparative antihypertensive strategies. This review discusses whether the relevant literature allows for the conclusion that RAAS intervention has renoprotective effects in addition to its effects on BP. In particular, the main evidence for a specific renoprotective action of RAAS blockade is provided by its consistent antiproteinuric action, which cannot completely be attributed to the reduction in BP. Indeed, other strategies that lower proteinuria without having an antihypertensive effect, such as lowering dietary protein intake or the use of non-steroidal antiinflammatory drugs, appear to have a renoprotective effect as well. Interestingly, a consistent finding across different intervention studies is that the more proteinuria is reduced the better the kidney appears to be protected. Therefore, it is concluded that agent-characteristics of RAAS intervention (i.e., antiproteinuric properties) independently influence renal function loss in addition to its BP-lowering effect. Future studies should further explore the renoprotective benefit of non-antihypertensive intervention measures, alone and in combination with antihypertensive strategies.     

Breast reduction: Evolution of a technique—A single vertical scar

In the past 20 years, patients have become more critical about the result of a breast reduction operation. Natural lasting shape and minimal residual scarring are now expected by most of the candidates to that surgery. In 1969 the author described a vertical technique that achieved reduction and good shape but the end of the vertical scar could be seen below the brassiere line. In 1977 the author modified the technique by adding a small horizontal scar that eliminated the yisible part of the vertical scar. In this article the author demonstrates that the same technique he described in 1969 and modified in 1977 can produce a single residual vertical scar if properly used.     

Shoulder dislocation—a modified reduction technique for anterior and inferior dislocations

Introduction

This modified reduction technique reduces trauma and morbidity for anterior and inferior dislocations, is easy to perform, and is reliable.

Method

The procedure uses a “three directional pull” as follows: (1) Linear traction of the affected arm as it lies in the “position on arrival” in the Emergency Room. (2) Counter traction in the opposite direction. (3) The “third force” (a modification) is a sustained, increasing traction with a 2–3 in. broad sling placed around the neck of the humerus, pulling in the direction of 2 o'clock (left shoulder)/10 o'clock (right shoulder) in line with the lateral border of the scapula [runs parallel to the face of the glenoid]. Reduction is generally done under sedation, but general anesthesia used on the elderly and osteoporotics makes the procedure easier, safer, and quicker. Immobilization is in “internal rotation” for 3 weeks.

Result

Reduction is either “spontaneous” or achieved in a maximum of three precisely graded attempts undertaken in quick succession in full “three directional traction mode,” using a much reduced range of abduction and external rotation than that used in Kocher's technique.

Conclusion

The “third force” is the crucial GUIDING force which helps to unbutton the head of the humerus from the rent in the capsule and/or “glide” the head effectively on to the glenoid. It will counteract or minimize muscle spasm. There was 100 % success in the 30 cases reduced by this technique over a period of 2.5 years.     

Can the use of a terminal device augment plantar pressure reduction with a total contact cast?

HYPOTHESES/PURPOSE: Total contact casting (TCC) has been shown to promote the healing of plantar neurotrophic ulcers by reducing plantar pressures and has become the established treatment standard by which all others are measured. The purpose of this study was to determine if terminal cast devices (cast shoes and heels) significantly affect the amount of plantar pressure reduction when used with a total contact cast. METHODS/RESULTS: Plantar pressures were measured in the right feet of 28 healthy adult volunteers using the Novel EMED PEDAR system (Novel GmbH, Munich, Germany) for six conditions: athletic shoe (i.e., control), TCC alone, TCC with a conventional cast shoe (EBI, Parsipanny, NJ), TCC with a custom rigid rocker cast shoe (NPS, St. Louis, MO), TCC with a rubber rocker heel (Cast Walker, DM Systems Inc., Evanston, IL), and TCC with a traditional flat rubber heel (Zimmer, Warsaw, IN). Peak plantar pressures were recorded from the forefoot, midfoot, and hindfoot. Analysis of variance (ANOVA) was used to determine statistical significance. The greatest reductions in forefoot plantar pressures compared to the athletic shoe control were seen in the TCC with the conventional cast shoe and the TCC with the rigid rocker shoe; a mean plantar pressure reduction of 30% was observed for both conditions (p < .001). Significant midfoot plantar pressure reductions (p < .001) were achieved with the TCC alone, TCC with the conventional cast shoe, TCC with the rigid rocker heel, TCC with the flat rubber heel, and TCC with the rubber rocker heel. Mean reductions were 42%, 51%, 47%, 40%, and 46%, respectively. While athletic shoe peak hindfoot pressures were only reduced by 15% by TCC alone, the addition of the rubber rocker heel to TCC reduced athletic shoe pressures by 32% and the addition of the flat rubber heel to TCC reduced athletic shoe pressures by 29%. The reductions with TCC and the heels were both significant when using the athletic shoe as the control (p < .001) and the TCC alone as the control (p < .05). CONCLUSION: Plantar pressure reduction with TCC can be augmented with the addition of a terminal cast device and the effects shown in this study are significantly different than previously reported. These results suggest that terminal cast devices should be chosen according to location of the neuropathic ulcer. In this study, forefoot pressures were reduced the most with TCC and either the conventional cast shoe or the rigid rocker shoe. The authors therefore recommend these combinations for forefoot ulcers. TCC alone or combined with any of the terminal devices proved equally effective for midfoot plantar pressure reduction. Hindfoot ulcers should be treated with TCC and the rubber rocker heel or the flat rubber heel as these provided the best hindfoot pressure reductions.     

To a margin reduction in the dermatofibrosarcoma protuberans? Retrospective study of 34 cases

INTRODUCTION: The dermatofibrosarcoma protuberans (DFSP) is a rare but not exceptional tumour. Surgical treatment should contain a wide excision to avoid local recurrence. MATERIAL AND METHOD: We report a retrospective study of 34 cases treated by the same team from 1994 to 1999. In this series, only 4 cases (12%) presented recurrences after previous treatment by the other teams. In all cases, surgical resection was performed with 3 cm lateral margin and a disease free anatomic layer removed with the tumour. RESULTS: The mean of follow up was 60 months. There was no recurrence case in our 34 patients during this period. We compare our results with those, from others teams described in international literature since 1951. Margins and results are similar with some teams who practice the Mohs surgery. CONCLUSION: These data are in favour of a reduction of the lateral margins in classical surgical procedure of DFSP. They should be consolidated by a follow-up in longer term with a prospective study.     

Does a reduction in dialysate sodium improve blood pressure control in haemodialysis patients?

Introduction: There has been debate as to the value of lower sodium dialysates to control blood pressure in haemodialysis patients, as sodium is predominantly removed by ultrafiltration. Methods: Re‐audit of clinical practice following reduction in dialysate sodium concentration. Results: Overall dialysate sodium concentration decreased from 138.9 ± 1.7 to 137.8 ± 1.7 mmol/L (mean ± standard deviation), resulting in a reduction in pre‐ and post‐dialysis mean arterial pressure (MAP) of 4 mmHg (from 100.6 ± 15.6 to 97.1 ± 15.6, P < 0.01 and from 91.7 ± 15.6 to 87.1 ± 14.6, P < 0.001 respectively), yet fewer patients were prescribed antihypertensives (49.6 vs 60.6%), and less antihypertensive medications/patient (mean 0.86 vs 1.05), ultrafiltration requirements (2.8% vs 3.2% body weight, P < 0.001), and symptomatic intradialytic hypotension (0.19 vs 0.28 episodes per week, P < 0.001). A multivariable model showed that for a dialysate sodium of 136 mmol/L, younger patients had higher MAP than older patients (0.35 mmHg lower MAP/year older; but with a dialysate sodium of 140 mmol/L, there was minimal association of MAP with age (0.07 mmHg higher MAP/year older). Conclusion: Change in clinical practice, amounting to a modest reduction in dialysate sodium was associated with a reduction not only in pre‐ and post‐dialysis blood pressures, but also ultrafiltration requirements and symptomatic intradialytic hypotension. However, this effect on blood pressure was most marked for older patients and women, within minimal effects for younger patients, and lesser effects for men, suggesting that dialysate sodium reduction alone may help improve blood pressure control, but requires additional factors such as dietary sodium restriction to be effective in younger male patients.     

Spontaneous reduction of dissociated components of modular bipolar hip prosthesis—a case report

Three years after modular bipolar hemiarthroplasty for avascular necrosis of the femoral head, a patient's modular head and neck components became dissociated following a minor twist of the lower limb. Spontaneous reduction of the components took place subsequently while the patient was asleep. The mechanism of dissociation is discussed. This unusual late traumatic head and neck dissociation followed by spontaneous reduction has not been reported previously.     

Three-dimensional correction of scoliosis by a double spring reduction system as a dynamic internal brace: a pre-clinical study in Göttingen minipigs

BACKGROUND CONTEXTAdolescent idiopathic scoliosis (AIS) is a major skeletal deformity that is characterized by a combination of apical rotation, lateral bending and apical lordosis. To provide full 3D correction, all these deformations should be addressed. We developed the Double Spring Reduction (DSR) system, a (growth-friendly) concept that continuously corrects the deformity through two different elements: A posterior convex Torsional Spring Implant (TSI) that provides a derotational torque at the apex, and a concave Spring Distraction System (SDS), which provides posterior, concave distraction to restore thoracic kyphosis.PURPOSETo determine whether the DSR components are able to correct an induced idiopathic-like scoliosis and to compare correction realized by the TSI alone to correction enforced by the complete DSR implant.STUDY DESIGN/SETTINGPreclinical randomized animal cohort study.PATIENT SAMPLETwelve growing Göttingen minipigs.OUTCOME MEASURESCoronal Cobb angle, T10-L3 lordosis/kyphosis, apical axial rotation, relative anterior lengthening.METHODSAll mini-pigs received the TSI with a contralateral tether to induce an idiopathic-like scoliosis with apical rotation (mean Cobb: 20.4°; mean axial apical rotation: 13.1°, mean lordosis: 4.9°). After induction, the animals were divided into two groups: One group (N=6) was corrected by TSI only (TSI only-group), another group (N=6) was corrected by a combination of TSI and SDS (DSR-group). 3D spinal morphology on CT was compared between groups over time. After 2 months of correction, animals were euthanized.RESULTSBoth intervention groups showed excellent apical derotation (TSI only-group: 15.0° to 5.4°; DSR-group: 11.2° to 3.5°). The TSI only-group showed coronal Cobb improvement from 22.5° to 6.0°, while the DSR-group overcorrected the 18.3° Cobb to -9.2°. Lordosis was converted to kyphosis in both groups (TSI only-group: -4.6° to 4.3°; DSR-group: -5.2° to 25.0°) which was significantly larger in the DSR-group (p<.001).CONCLUSIONSThe TSI alone realized strong apical derotation and moderate correction in the coronal and sagittal plane. The addition of distraction on the posterior concavity resulted in more coronal correction and reversal of induced lordosis into physiological kyphosis.CLINICAL SIGNIFICANCEThis study shows that dynamic spring forces could be a viable method to guide the spine towards healthy alignment, without fusing it or inhibiting its growth.     

Absence of the left portal vein: a difficulty for reduction of liver grafts?

BACKGROUND: Absence of the portal bifurcation is exceptional and characterized by an absent extrahepatic portal vein bifurcation, the right portal vein only being at the porta hepatis. There is no extraparenchymal left portal vein. This may represent a problem in liver splitting, reduction, and living related transplantation. METHOD: A case was encountered during reduction of a cadaveric liver allograft to a left lateral segmental graft from a 40-kg cadaveric donor to a 15-kg recipient. The portal venous inflow was reconstructed with a vein graft via a novel extrahilar approach to the left portal vein at the umbilical fissure. RESULTS: This graft was used successfully in a 3-year-old child requiring transplantation for a failed Kasai operation for extrahepatic biliary atresia. The child is now well, 1 year posttransplant, after an uneventful postoperative course with good portal flow within the graft. CONCLUSION: The situation of an absent left portal vein extrahepatic course should not preclude splitting or reduction procedures. The innovative technical solution, we propose, should add to the armamentarium of the liver transplant surgeon contemplating a left lateral segmental graft for the paediatric liver transplant recipient.     

Open reduction and internal fixation in a case with transscaphoid perilunate dislocation 8 months after the injury: a patient with a 5-year follow-up

The management of perilunate dislocations diagnosed later than three months continue to elicit debate with literature being scarce. We report a 22-year-old male with transscaphoid perilunate dislocation who reported to our hospital 8 months after sustaining the injury. Open reduction was done along with bone grafting. Five years after the surgery the patient is symptom-free with an excellent range of motion.     

Is a gradual reduction of stiffness on top of posterior instrumentation possible with a suitable proximal implant? A biomechanical study

Background Context

Proximal junctional kyphosis (PJK) is a challenging complication after rigid posterior instrumentation (RI) of the spine. Several risk factors have been described in literature so far, including the rigidity of the cranial aspect of the implant.

Seminal oxidation–reduction potential as a possible indicator of impaired sperm parameters in Turkish population

Oxidative stress (OS) has been shown to have a key role in male infertility. Recently, a new measurement method has been developed to measure the overall oxidation–reduction potential (ORP) in a semen sample known as the MiOXSYS system. The aim of this study was to investigate the correlation of sperm parameters with oxidative stress levels determined by ORP and to evaluate whether the current limit is able to distinguish abnormal sperm parameters from normal ones in Turkish population. Semen samples of 121 patients who applied for infertility investigation were divided into two groups as (OS +; n:39) and (OS −; n:82). Semen parameters were compared between groups. Sperm concentration, total motility and progressive motility were found to be significantly lower in OS (+) patients compared to those OS (−), while immotile sperm count was significantly higher in OS (+) patients. Oxidative stress determined by MiOXSYS system was found to be related to reduced sperm parameters in Turkish population, which may be used as an indicator of poor sperm parameters and a support to routine semen analysis. In addition, recommended reference value was found to be reliable in distinguishing normal from impaired semen parameters.     

NSAID as pre- and postoperative medication —a potential risk for bleeding complications in reduction mammaplasty

A cluster of bleeding complications in previously healthy women operated on for macromastia by reduction mammaplasty prompted a retrospective study of 293 patients treated during 1991–1992. Nine out of ten patients with profuse intraoperative bleeding had received the NSAID diclofenac (Voltaren) as part of premedication. Eight out of 20 postoperative haematomas were noted in patients treated with the NSAIDs diclofenac (Voltaren) or ketorolac (Toradol) for postoperative analgesia. These findings indicate that NSAID treatment increases the risk of intra- and postoperative bleeding complications in certain patients operated on for macromastia by reduction mammaplasty.The Department of Plastic Surgery was formerly (until 30 June 1994) located at the Sabbatsbergs Hospital, Stockholm Correspondence to: L. Blomqvist